Thursday, November 29, 2012

Preventing Venous Thromboembolism(VTE) in Hospitals

To prevent clots or to bleed, that is the question.

Anonymous\

November 29, 2012 -Today’s subject is how hospitals can prevent venous thromboembolism VTE), a leading cause of hospital deaths.Physicians may be indirectly responsible for some of these deaths because the underestimate the danger of clotting and overestimate the risk of bleeding through use of heparin or other anticoagulants.

According to Greg Maynard, MD, of the Division of Hospital Medicine at the University of California.VTE is perhaps the single greatest cause of morbidity and mortality in U.S. hospitals.

VTE:

·accounts for 350,000 to 650,000 hospital cases each year

·causes 100,000 to more than 250,000 deaths

·occurs mostly in hospitals

·leads to 10% of hospital deaths

·accounts for many hospital readmissions.

VTE risk factors are present in as least one of every two hospital patients.

The risk factors are:

Stasis

-any over age 40

-immobility

-congestive heart failure

-stroke

-paralysis

-spinal cord injury

-polychythemia

-severe COPD

-anesthesia

-obesity varicose vein

Hypercoagulability

-cancer

-high estrogen states

-inflammatory bowel disease

- nepthrotic syndrome

-sepsis

-pregnancy

- thrombophlebitis

Endothelial damage

-surgery

-prior VTE

- central veinline

- trauma

Since these conditions are so common,it makes sense to have set orders for anti-embolic stocking and intermittent pneumatic compression for most bed-ridden patients and anticoagulants for those are high risk.Those at high risk include patients undergoing hip or knee replacements and those with deep venous thrombosis.

How to institute and implement these preventive steps is easier said than done. No comprehensive prophylactic model exists. A number of solutions have been suggested.

-An electronic alert system based on risk factors in chart.

-Team education

-Standardized orders

-Periodic audits to alert physicians and staff to complications

There is no perfect preventive system, but most systems that have been introduced have led to a 40% to 45% reduction in thromboembolic episodes and deaths.Tweet:Venous thromboembolic (VTE) cause 10% of hospital deaths. As many as 40% to 45% ov VTE events can be prevented through systematic preventive measures.

Wednesday, November 28, 2012

101 Letters from Kaiser Chairman
and CEO To Kaiser Employees

Letters
are among the most signifiant memorial a person can laeve behind them.

Johann Wolgang von Goethe (1749—1832)

November 28, 2012 -George Halvorson, chairman and CEO of Kaiser Permanentate since
2002,has publisheda book of 101letters he wrote to employees (
he prefers to call them “people” and “colleagues”) he has written each week since September
27, 2007.The letters are delivered
every Friday to every Kaiser employee. In his letters,Halvorson
cheerleadsfor
Kaiser – praising the organization for every award received, for every increase
in health status of Kaiser patients,for every documented increase in quality or outcomes,for every step forward in information
technology, for every measurable achievement leading to decreases in mortality or
morbidity.

Halvorson candidly tells us why he writes these
letters.

“I do love writing letters..For me writing letters creates a lovely
mindset. I am constantly looking for good things to celebrate. Idefinitely believe that I now know quite a
bit more about us as an an organization and as a care system had I not been
consistently writing these weekly celebration letters.”

Halvorson has much to celebrate. Kaiser has cut
HIV-AIDS mortality rates in half, reduced pressure ulcers by 60 percent, prevented the number of broken bones in seniors
by 30%, and dramatically reduced death rates for sepsis, heart attacks, cancers, and diabetes while connecting members and caregivers with
electronic records, allowing patients to get their medical records and to email
their doctors by IPhone, Android, and other Smartphone., and teaching the
world how to provide patient-focused , electronially connected team care resulting
in measurable and continuously improving
medical outcomes.

The letters are personal,pithy, and uplifting. The letters have
proven to be an effective means of communicating to "colleagues" in a health plan and hospital
system that generates $50 billion in revenuesand which has 9 million members,
200,000 caregivers, and 600 owned sites. Halvorson thinks big by constantly emphasizing improvements, large and small, that make a big difference in people's health and survival..

Tweet:For five years, Kaiser Chairman and CEO, has written weekly letters of celebration to the 200,000 caregivers who make up Kaiser Pemanente.

Tuesday, November 27, 2012

Donald
Hall (born 1928), Poet, Caregiver, and Sickness Student

"Dying is simple," she said.
"What's worst is… the separation."
When she no longer spoke,
they lay along together, touching,
and she fixed on him
her beautiful enormous round brown eyes,
shining, unblinking,
and passionate with love and dread.

Donald
Hall,“The Last Days,” except from poem
in his book Without,dedicated to his beloved wife, Jane
Kenyou(1947-1995), a fellow poet

November
27, 2012 - I’m
just back from a 2 day trip to Wilmot, New Hampshire, Eagle Pond Farm to be
precise.I travelled there with my son,
my wife, and two friends to visit Donald Hall, truly a man of letters, poet laureate of the
United States from 2006 to 2007, and winner of multiple literary prizes.

Before going ,I read two of Hall’s recent books, Unpacking
the Boxes, A Memoir of a Life in
Poetry (2008), and The Best Day the Worst
Day: Life with Jane Kenyon (2005).

In these two books, Donadl Hall describes own illness (carcinoma of the colon, with liver
metastases,partial liver resection, and
20 year cure) and those of his young wife, 19 years his junior,who suffered from a severe manic-depression
bipolar disorder , partially controlled by antidepressive agents, and lymphoblastic leukemia, which was
treated with bone marrow transplant and a host of chemotherapeutic drugs.

What struck me about his books was not only his
storied literary career (he knew the greatest poets and writers of his time and
helped found The Paris Review),
buthis harmonious interactions with and understanding of the medical profession, his extraordinary
grasp of the clinical details of illness, and his dedication as a compassionate
caregiver to his wife, with her painful,exhausting, stormy, and nerve-wracking illnesses. His memories of her are a touching tribute to
a fine human being and a great poet. Hall's booksell well to this day.Donald has not giving up the writing
life.He now has an essay running in Playbook and still appears in variety of
other well known publications.

Sunday, November 25, 2012

November 25, 2012 -I spent the morning working on the foreword and introduction to my new book,The Physicians Foundation: A New Voice of
American Medicine.

The book will be out in a week or two.

Here is the tentative foreword foreword and introduction

Foreword

The Physicians
Foundation – A New Voice of American Medicine

With this Survey of
America’s Physicians, The Physicians Foundation has endeavored to provide a
“state of the union” of the medical profession. The survey was sent to over
630,000 physicians – or over 80 percent of physicians in active practice – and
represents the Physicians Foundation’s efforts to provide as many physicians as
possible with a voice.

A Survey of American Physicians, The
Physicians Foundation, September 24, 2012

This second little book in as series of 12 books on health reform consists of Medinnovation interviews and blogs relating
to the Physicians Foundation over the last five years. My title A New Voice of American Medicine is
testament the fact that the Physicians Foundation is relatively new. The
Foundation is a nonprofit, non-lobbying organization founded in 2003 as the
result of a settlement between 19 state and country medical societies and major
HMOs.

The Foundation is acutely aware that American Medicine is in state
of profound transformation. The Foundation’s voice is objective, analytical,
rational, and nonpartisan. It fears the legacy of health reform will be a deep
and lasting shortage of physicians with limited access for patients.

The
Foundation’s mission is to advance, defend, and salvage private practice.
This is a worthy cause. Private physicians provide 80% of America’s health
care. Indeed, private physicians are the very foundation of American medicine. The
Foundation issues grants, commissions white papers, does research studies, and
conducts far-reaching surveys on the state and direction of American Medicine.

Introduction

One
voice for the Physicians Foundation that
is particularly compelling is that of Phillip Miller. Vice-President of
Communications for Merritt Hawkins and Associates.This national recruiting firm is close to
the ground and to reality.It speaks ever day to
physicians seeking a job and to hospitals, medical groups, and other
organizations seeking physicians.

Phillip knows the lay of the physician land, and he
is beautiful writer. He has written a series of books on physicians – their needs,
wants, and dilemmas His
books include Will the Last Physician in
America Please Turn Off the Lights, A Look at the Looming Physician Shortage,
In Their Own Words: 12,000 Physicians Reveal Their Thoughts on on Medical Pratice
in America.

Three years or so ago,I put the Physicians Foundation in touch with
Phillip for the purpose of conducting a national survey of physicians. Philip helped Merritt Hawkins survey 100,000 physicians The survey appeared in October 2010. Phillip served as the principal author.

Here is his summary of the White Paper based on the
survey.His summary captures perfectly
the quandary in which practicing
physicians find themselves. The White Paper, prophetically, is entitled Health Reform and the Decline of Physician
Private Practice.An alternative
title might have been American Physicians
– Victims of Their Own Success.In
any event, here are Phillip’s wordsThe words
will serve nicely as an introduction into the works of the Physicians
Foundation.

“Like society itself, medical practice has been evolving
rapidly in the United States over the last 50 years, in response to
technological, economic, demographic, political and related influences.Passage of the Patient Protection and
Affordable Care Act (“health reform”) promises to acceleate this evolution in a
variety of ways.

The Physicians Foundation called upon Merritt Hawkins
and an Advisory Board of healthcare experts to assess how health reform is
likely to affect practices in the United States. This White Paper reflects the results
of Merritt Hawkins and the Advisory
Board’s analysis.

"1)Health reform
is comprised of two elements” “Informal reform,” (i.e. societal and economic
trends exerting pressure on the current healthcare system independent of the Patient
Protection and Affordable Care Act) and “formal reform," (i.e. The provisions
contained in the Act itself).

2)The current
iteration, both formal and informal,
will have a transformative effect on the health system.This time, reform will not be a “false dawn,”
analogous to the health reform movement of the 1990s but will usher in
substantive and lasting changes.

3) The independent private physician
private practice model will be largely, though not uniformly replaced.

4)Most physicians will be compelled to consolidate
with other practitioners, become hospital employees, or align with large
hospitals and health systems for capital, administrative, and technical
resources.

6)Reform will drastically increase physician legal
compliance and potential liability under federal fraud and abuse
statutes.Enhances funding for enforcement,
addititional latitude for “whistle blowers,” and suspension of government’s
need to prove “intent” will create a compliance environment many physicians
will find problematic.

7)Reformwill exacerbate physician shortages, creating
access issues for many patients. Primary
care shortages and physician maldistribution willnot
be resolved.Physician will need to redefine their roles and rethink
delivery models in order to meet rising
demand.

8)The imperative to care for more
patients, to provide higher perceived quality, at less cost, with increased reporting
and tracking demands, in an environment of high potential liability and problematic
reimbursement, will put additional stress on physicians, particularly those in
private practices. Some physicians will respond
by opting out of private practice or by abandoningmedicine altogether, contributingto the physician shortage.

9)The omission in reform of a “fix” to the Sustainable Growth
Rate (SGR) formula and of liability
reform will further disengage physicians from medicine and limit patient
access.SGR is unlikely to be resolved
by Congress and will probably be folded into new payment mechanismswithin the next five years .

10)Health care reform was necessary and inevitable.The impetus of informal reform would likely
have spurred many of the changes above, independent of formal reform.Net gain in coverage, quality and costs are
to behoped for. But the transition will
be challenging to all physicians and onerous for many.”Conclusion

For
physicians, the future is not what it used to be.For the present,as revealed by the Physicians Foundation's research,
and White Papers, the majority of physicians have responded unfavorably to the
passage of health reform and are experiencing
increased patient loads with decreased
financial viability.They are altering
their practices to reduce patient access, and are taking steps to minimize 3rd
party influences through hospital employment,
part-time work,locum tenens,or concierge practices. What the future holds no one knows for
sure,nor do we know the fate of
Obamacare.

What follows
in this 2ns book in a series on health reform are interviews conducted
and blogs written over the last five years into insights the Physician Foundation. has contributed to knowledge of
the reform process. Tweet: Private American medical practices are in a state of decline and transition to other models of health care delivery.

Saturday, November 24, 2012

Thursday, November 22, 2012

Books– New Voices of Health Reform: The 3 R’s-Rhyme, Reason & Reality. A Modern History of Reform

November 20, 2012 -I am now engagedin the process of producing a series of books. These books are collections of my Medinnovation blogs on specific subjects written over the last six years.

The first of these books Physicians, Poetry & Humor is now available.It may be ordered by calling Bronwen Blaney at the RJ Julia’s bookstore in Madison, CT, at 1- 203-245-3959 and asking for a single or multiple copies of the book.It sells for $12.95 + 6% sales tax + shipping charge.The books will be 175 to 250 pages long.

Other books which have been completed but are not yet available include:

·Physician Culture & American Culture

·The Physicians Foundation – New Voice of American Medicine

·Primary Care & Specialty Care

·Medicare& Medicaid- Where Now?

·Medical& Health Care Innovation

·Electronic Health Records – Boon or Boondoggle

·Physician& Hospital Relationships

·Malpractice& Tort Reform- Physician Hot Button Issue

·Accountable Care Organizations – Who is in Charge?

·A Book of Health Reform Book Reviews

I will be announcing the availability of these books as they go online and are available in paperback. The first book, Physicians, Poetry & Humor would be an ideal oChristmas book for physicians or patients concerned about health reform

November
24, 2012 -In
the rarified world of social welfare reform,it is anathema to use the words “health,”
and “cash” in one sentence.It is one or
the other. “Cash” smells of “cold-hard cash,”“cash-and-carry.” It distracts from the world of human needs
and the social determinants of health.

Instead what people deserve, say advocates of the
all-encompassing social welfare state, are conditions in which all people can be healthy, including
equal opportunities for “education, housing, employment, living wages, access
to health care, access to healthy foods and green spaces, occupational safety,
hopefulness, and freedom from racism, classism, sexism, and other forms of
exclusion, marginalization, and discrimination based on social status.”
(Wilkinson, R, Marmot M., “Social Dterminants of Health – The Solid Facts, 2nd
Edition, Copenhagen: The World Health Organization, Regional Office for Europe,
2003). Overly generous social welfare programs in socialist countries with aging populations and low birth rates are a huge factor in bringing their economies of these countries to their knees.

No mention in the WHO report is made of “profit,” “prosperity,” and “economic
growth,” as the engines that make possible this utopian state of affairs.And no
mention is made either in this week's New England Journal of Medicine (Jennifer K.
Cheng, MD, “Confronting the Social Determinants of Health – Obesity, Neglect,
and Inequity, November 22, 2012) of these factors.Instead the latter article ends with a quote
from Theodore Roosevelt, “The welfare of each of us is dependent fundamentally
upon the welfare of all of .”

While one can hardly disagree with any of these sentiments, the fact remains that all of us, including
physicians,have to pay our bills.In the case of physicians, we somehow have to
compensate for 15 years spend in education and training outside the economic
mainstream,paying for crushing medical
school debts in the neighborhood of $150,000 to $200,000, the cost of malpractice
insurance and complying with onerous government regulations.

One physician response to the wealth and health
problem,i.e. cash-only practices,is clearly brought out in a yesterday New York
Times piece (Paul Sullivan, “Wealth Mattters: Dealing with Doctors Who Take Cash Only,” November
23, 2012).

The author describes the case of his 4 month old
sleepless daughter.A pediatrician drove
an hour from his practice to see the little girl, spent an hour with the baby
and her parents,spent another hour
returning to his practice, and submitted a bill of $650 not covered by
insurance.The insurance company would
have paid $285.

The reporter says he and wife liked the doctor and
the attention,but he wondered what
motivated doctors to go to cash-only practices,The reasons he cites are higher income, more
time with patients,lower overhead,more patient satisfaction,greater cash flow, and less third party
harassment.The problem for patients, of course, is more
out-of-pocket cash, and increasing lack of affordability ofhealth care.

From 30,000 feet the problem of cash-only and concierge
practices,which involves less than 10%
of doctors but is growing,is social
reform versus economic reform, or put another way, health risks versus economic
risks.

Stanford Owen,
MD, an internist in Gulfport, Mississippi, who practices cash-only medicine,
summed up the situation.Dr.
Owen says he is happy and feels that he is practicing family medicine the way
his father and grandfather did. “Primary care is the least pay, the most work
and the most responsibility,” he said. “Under this model, you can make a good
living. You won’t get rich, but neither did the doctors in the 1960s.”

Tweet:Primary care doctors are switchingto cash-only medicine to avoid low 3rd
party pay, to make more money, and spend more time with patients.

Friday, November 23, 2012

Americans and Their Medical Machines

The real problem is not whether machines think, but whether men do

B. F. Skinner (1904-1996), Contingencies of Reinforcement(1969)

If you are designing a machine, you had better think of everything, because a machine cannot think for itself.B. Zimmerman, C. Lindberg, P. Pisek, Edgeware: Insights from Complexity Science for Health Care Leaders, 1998

Preface: From time to time, I review my blogs to see what past blogs readers are reading. Here is a current favorite, from May 9, 2010.

Obsession with medical technologies and machines characterizes American’s cultural expectations. We tend to think of our bodies as perpetual motion machines, to be preserved in perpetuity. If the face of our machines sag, we lift its faces up. If our pipes clog, we roto rooter them out or stent them. If impurities gum up our machinery, we filter them out. If our joints give out or lock up, we replace them. If we want to remove something in the machine’s interior, we take it out through a laparoscope. If the fuel or metabolic mix is wrong, we alter the mix or correct the metabolic defect with drugs If anything else goes wrong, we diagnose it and rearrange it electronically.

We are reluctant to let nature take its course. We rely on half-way technologies and machines to do the job of keeping us looking young, active, functioning , and alive. This fixation on machines and technologies is the big reason American health care is 50% more costly than that of other nations. With rapid access to machines and our reliance on them, we deliver a different product than other countries – more technologies and more machines, faster and more often. Our belief system is : Give a specialist a machine, and he or she will do the job, and we or the government will pay for it.

We love machines - heart lung bypass machines, dialysis machines, heart rhythm machines, imaging machines, Internet-run machines, ventilation support machines to keep us alive at the end of life. . Patients and lawyers expect us to use these machines, doctors constantly innovate to produce more machines, and we tend to use them – no matter what the cost.

Go to a cardiology convention, and you will witness display after display of heart rhythm pacemakers. Go to an orthopedic convention, and you will think you are in an industrial exhibit, with new devices as far as the eye can see and the mind can comprehend. Go to an orthopedic operating room, and you will hear the sounds of hammers and chisels and rods being inserted. Go to a hospital convention, and much of the chatter will be about new technologies and machines that attract more patients and more specialists, reverse the ravages of disease, and to enrich the bottom line.

The latest and most talked about machine in hospital marketing and in the hands of surgical specialists such as urologists, heart surgeons, and gynecologists is the da Vinci surgical robot, a $1.4 million machine named after Leonardo da Vinci. It is designed to be less invasive, to cut blood loss, to minimize complications, to increase hospital market share and revenues, and to attract both patients and specialists to hospitals.

The price is high, $1 million to $2.25 million per machine depending on the model, $140,000 a year for maintenance, and $1500 to $2000 per procedure for replacement parts. The manufacturer of da Vinci, Intuitive Surgical, Inc, must be doing something right. Last year it had a profit of $233 million on sales of $1.05 billion. It is deployed in 853 hospitals, large and small.

But, as with all medical machines, da Vinci is not infallible . It relies on the expertise and experience of its physician users (See Wall Street Journal, May 5, “Surgical Robot Examined in Injuries.”)
The human body is not a machine, and not all of its problems and eccentricities , given the individualities and variabilities of the human condition, lend themselves to automatic or flawless operation and correction. Complications happen. Human judgment is still required.

Title
of 2002 book by investigative journalist Eric Schlosser on social consequences of
fast food

November
23, 2012 -The
Patient Affordability Care Act (aka Obamacare) stipulates that on January 1,
2014: Every full time employees must be provided with comprehensive medical
coverage if the company employs more than 50 full-time workers.

To fast food corporations and fast-food franchise
owners, who operate on razor-thin margins,this stipulations hits like a profit-killing thunderbolt.How do you stay in business in a competitive marketplace,
when this stipulation would dramatically increase your expenses for providing
health benefits. “Comprehensive” governmentsanctioned health benefits, are, by definition,more expensive than currently provided in
private plans. If you do not choose to
provide government approved plans,you
will be fined $2000 for each full-time employee.For Appleby’s in New York City along, this
would cost $600,000.For Applebys
nationwside for th other firms like Papa Johns, Dennys, McDonalds, Burger King, and
Wendy’s, the cost would be enormous, in the billions of dollars.

If you are a business planner for a fast food
restaurant chain, what are your option?

·Roll back expansion

Do not hire more full time employees.

Reduce thousands of employees to part-time,
under 30 hours each week.

·Raise prices, as Papa Johns has done by
increasing the price of its pizzas.

If you are a worker for these chains, your options
are:

·Pay for your own health insurance with
your greatly reduced income.

·Work for multiple fast food restaurants.

·Go on Medicaid, for which you may now
quality and accept the fact that not enough doctors accept Medicaid patients
and he benefits are less than private plans.

When Obamacare passed, it was no doubt done so with
good intentions.

Unfortunately,as Samuel Johnson observed, “The road to hell is paved with good
intentions” and adverse consequences for those it was intended to help – lower
incomes, paying for one’s health insurance,or going on Medicaid, if you qualify.Good intentions have consequences.

Tweet:The
Obamacare provision that businesses with more than 50 full time workers
must offer comprehensive health benefits has adverse consequences

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.